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Quarantine/Isolation Support

Significance. Health call centers can assist with monitoring
and supporting patients in quarantine and isolation. Several reports are
published of managing and monitoring by telephone those placed in quarantine
for SARS.2,
21-23 Other research has
indicated public support of the use of quarantine to control disease and for
monitoring the status of those in quarantine by
telephone.24
The Seattle/King County Advanced Practice Center offers a toolkit for
"Planning & Managing for Isolation & Quarantine"
(www.isolationandquarantine.com) to assist in proactively planning for
and managing the implementation of large-scale isolation and quarantine.
They suggest establishing a public health hotline and call center for public
inquiries and caution:

"In an emergency situation, focus on your expertise. Do not try
to reinvent yourself or your organization by taking on something outside
of what you know. Admit where your expertise ends and find the community
organizations with whom you can partner to acquire their expertise for
the response."

Community partners such as health call centers are well suited to assist
with monitoring or contacting those in quarantine and isolation, especially
if they had appropriate guidance and resources.

Scenarios. Of the 15 National Planning Scenarios, only the two scenarios
involving infectious diseases, Pandemic Influenza Outbreak and Plague Outbreak,
would potentially require the use of quarantine and isolation as disease
control measures and could benefit from using call centers. Though SARS outbreak
is not one of the DHS scenarios, SARs and other infectious diseases would
require planning and response capabilities similar to those for influenza
and plague scenarios.

Current Examples. Telephones were used to monitor those in quarantine in
the 2003 SARS outbreaks in
Toronto2 and
Taiwan.23 Public health
departments around the country currently use quarantine and isolation measures with
tuberculosis patients, and in Nassau, NY, they use videophones to monitor patient status
and compliance.22 The
Centers for Disease Control and Prevention (CDC) Division of Global Migration and Quarantine also has field stations at certain
airports when suspected infectious persons are identified on airplanes inbound
to the United States.29

Technology. Basic telephone technology is required to initiate periodic
calls to those assigned to home quarantine by public health agencies. Simply
having a staff person place calls on a single phone line can attain this
response capability. As larger numbers of people are placed in quarantine,
additional personnel and phone lines are needed to manage them. As the number
of those in quarantine reaches into the thousands (as in the Toronto and
Taiwan experiences), an IR system would be beneficial in automating those
periodic calls, recording those who answered and their reported health status,
transferring people who needed further attention to staff, and reporting
those that did not answer within the specified attempts for followup.

Staffing. Trained information providers could manage quarantine
monitoring and provide assistance and referrals according to established public health
agency protocols. Agencies like the American Red Cross could be used to help
support those in quarantine by delivering food or other supplies.

Proposed Resource. We have developed the Quarantine/Isolation
Monitoring Application to support quarantine and isolation monitoring strategies,
which would use an IR system. The application would free staff to handle only
callers needing further attention, such as those developing symptoms or those who
could not be reached (potentially noncompliant with quarantine). In the Taiwan
SARS experience, 113,132 people were quarantined with only 133 (0.1 percent)
having suspect or probable disease diagnosis. Of the 108 who were tested,
only 21 were SARS positive via polymerase chain reaction. Only 286 persons
(0.2 percent) were fined for violation of quarantine. This demonstrates that
less than 1 percent of those in quarantine needed much more than periodic
monitoring. Automating much of that monitoring with a tool such as the QI
Monitoring Application could be very useful. This application is summarized
here and fully described in Appendix
4, Developing an Interactive Response Tool.

QI Monitoring Application. The QI Monitoring Application has the capability
to automatically place outbound calls to individuals in home quarantine/isolation
to assess their current health status. The application calls the quarantined
person at specified times, provides messages in English or Spanish identifying
the purpose of the call, requires the person to select an option that reflects
his or her current health status (using temperature as a decision point),
transfers him or her to an information provider for assistance if indicated,
and provides information about who to call if he or she needs assistance
before the next monitoring call.

Though this application was developed for use with an IR system, it could
be used without such technology. The call flows, decision trees, and message
scripts could guide call center staff in how to handle calls and what information
to provide. The application could be adapted to other scenarios that might
require telephoning individuals, such as sheltering in place strategies or
followups to vaccinations. Public health agencies may want to develop referral
protocols and guidance for call center staff in handling situations in which
a quarantined individual needs food, medication, or financial assistance.

Outpatient Drug Information/Adverse Event Reporting

Significance. The CDC's Cities Readiness Initiative program requires
that participating cities prepare plans for mass prophylaxis with Strategic
National Stockpile assets. Depending on the potential for exposure, this
could result in thousands or millions of people being dispensed antibiotic
medications. Health call centers can support these efforts by providing information
about the incident and the supplied medications, as well as collecting any
potential adverse event reports.

Scenarios. This response capability primarily is applicable for the
two National Planning Scenarios involving agents treated with antibiotics: Aerosolized
Anthrax and Plague Outbreak. Other scenarios that involve either mass vaccinations
(Pandemic Influenza Outbreak) or wide-scale use of medications for treating
radiation exposure (Nuclear Detonation, Radiological Dispersal Devices) or
potentially Food Contamination may also require this response capability.

Current Examples. The HELP program has collected adverse event
information regarding smallpox using the Vaccine Adverse Event Reporting System (VAERS)
form fields (http://vaers.hhs.gov/).28 In addition, drug
information centers collect information for the Food and Drug Administration's (FDA) MedWatch reporting program
(http://www.fda.gov/medwatch/),
as well as handling drug information and identification calls. Poison control
centers have much experience in handling drug identification calls, which
comprise 61 percent of their non-exposure
calls.9

Technology. In addition to the call center technology and
data collection systems mentioned previously, staff would require drug identification
resources such as online searchable databases such as Drugs.com
(www.drugs.com/pill_identification.html) and RxList.com (www.rxlist.com/interact.htm)
or commercial database IDENTIDEX System (www.micromedex.com/products/identidex/).
MedWatch and VAERS form data fields could be incorporated into data collection
systems or paper forms could be completed.

Staffing. Trained information providers could manage
providing drug identification assistance to the public. Clinicians would be
more appropriate for collection of adverse drug or vaccine event reports.

Proposed Resource. We have developed the Drug Information (DI)
Application to support mass prophylaxis with antibiotic drug strategies using an IR
system. The IR system application would assist callers in the identification of the
drug they were given and provide them with information on how to take it
and its potential adverse reactions. The application would allow public health
agencies to concentrate on operating mass dispensing sites and allow health
care providers to care for those who are ill. This application is summarized
here and fully described in Appendix
4.

DI Application. The DI Application allows callers to identify
medications based on the appearance of the antibiotic drugs that are being dispensed
at POD locations during a public health emergency. The callers are given
clear directions from menu messages and can repeat messages or drug descriptions.
This application accommodates one language selection (English), but it could
be modified for additional language selections.

Though this application was developed for use with an IR system, it could
be used without such technology. The call flows, decision trees, and message
scripts could be used without technology to guide call center staff in how
to handle calls and what information to provide. The application could be
adapted to other scenarios that might require mass administration of medications
or vaccinations and to provide relevant information.

Mental Health Assistance/Referral

Significance. Call centers providing health information and support
will help to relieve anxiety and stress among the public, but some callers may
need further assistance. Call center staff can assist these callers by referring
them to community mental health resources.

Scenarios. Most of the 15 National Planning Scenarios will result in
varying degrees of community fear, panic, anxiety, and even depression.

Current Examples. Countless suicide prevention and
counseling hotlines currently exist and are run by trained mental health staff.
The National Suicide Prevention Lifeline provides a 24-hour toll-free service
that routes callers to crisis centers across the country
(www.suicidepreventionlifeline.org). Additionally, nurse advice lines are capable
of handling patients with depression. Poison control centers regularly receive
suicide and intentional harm calls.

Staffing. Information providers would not necessarily
be trained in assessing mental health concerns but could adequately provide
referral assistance with training. Clinicians trained in identifying mental
health warning signals would be an integral resource for assisting such callers.

Proposed Resources. No specific resources are proposed.
However, it is recommended that good risk communication principles be used for
handling callers who are anxious or under
stress.4
Call center staff should be trained on how to handle calls from those under
stress. The Kansas Department of Health and Education developed phone bank
operator training that includes communications protocols, techniques, and
role playing for a variety of health
emergencies.30
The CDC also offers good disaster mental health resources
(http://www.bt.cdc.gov/mentalhealth/).

It is recommended that call centers review the content of their recordings
and FAQs to determine if they can be improved to reduce caller anxiety. Using
a voice for recordings that is pleasant and that mentions appropriate reassurances
such as "there will be adequate supplies of medications for everyone" will
help to alleviate caller anxiety. Following unpleasant information with positive
statements also can help in many situations. The Center for Risk Communication
(www.centerforriskcommunication.com) provides information on communication
methods for high concern, high stress, or emotionally charged issues based
on behavioral-science research and practice.

4. Develop a mechanism to test and evaluate the model with a local exercise

HELP Model Testing

The HELP model has been tested in more than 3 years of daily operations
and response to several major health events. The HELP model has made it possible
for us to provide consistent, accurate, and up-to-date information during
bioterrorism exercises and public health emergencies in partnership with
the Colorado Department of Public Health and Environment. HELP served as
a proving ground for the implementation of some HEALTH concepts and strategies.
Since its launch, the HELP program has continually developed as it responded
to three major health events in Colorado: the deadliest WNV outbreak in the
United States (2003), an influenza outbreak with early increased pediatric
deaths (2003/2004), and an influenza outbreak during a vaccine shortage
(2004/2005).26,28
The HELP program provides a model for disseminating and collecting information
that, to date, has involved handling more than 75,000 calls related to several
health events and outbreaks.

The first test of the HELP model occurred on the day the program began daily
operations to support a WNV outbreak in Colorado. The service began answering
telephone calls at 7:00 a.m., and a press release announcing the first human
case of WNV in the State occurred within the next few hours. State health
department staff handled up to 1,000 calls regarding WNV the previous year
(first year of the outbreak in the State) and expected several times that
number during the second year of the outbreak because of its greater potential
to result in human disease. However, the 12,500 calls over the next 3 months
were much more than expected.

During the same period, human WNV cases surpassed 2,500, and human deaths
totaled 47. Figure 5 depicts the
average call volumes to HELP by hour of the day for the initial 7 weeks.
During that time, call volumes averaged greater than 1,500 calls weekly and 220
calls daily, with peak call volumes of 2,229 in 1 week, 524 in 1 day, and 178
in 1 hour. These call volumes accurately reflected the public's demand for
information, since all 96 channels (individual phone lines) dedicated to HELP
were never all used at once. If that were to occur, additional callers would
have received a busy signal, and we would have no means to determine the number
of callers that could not get through.

The drivers for these call volumes involved both the status of the outbreak
in the news each day (number of human cases and deaths) and the time of day
that such news was disseminated by the media. As
Figure 5 shows, hourly spikes
in call volume were related to times of television newscasts, usually featuring
the HELP toll-free phone number as part of the news crawler during updates.
Therefore, we began to staff up for certain hours to better accommodate those
volume surges. Staffing was usually limited to no more than four information
providers at a time (the number that our funding from the State health department
could support).

Therefore, we used our initial announcement to relay the
most requested information to alleviate a caller's need to speak with
staff. On average, 60 percent of callers listened to the recording and then
terminated the call; the remaining 40 percent chose to remain on the line
to speak with a staff person. This indicated to us that most callers were
having their concern addressed with recorded information; otherwise they
would have waited in queue to speak with a staff person (those waiting at
least 6 seconds past end of recording were counted as those needing to speak
with staff). It is important to keep announcements and recordings reasonable
in length—less then 30 seconds and only sparingly up to 1 minute. The
average of 60 percent of callers having their concern addressed by the initial
announcement has remained fairly constant over the last 3 years and for a
range of health events.

A strategy to assist those waiting in queue (which has at peak times reached
up to 20 callers with some waiting up to 30 minutes) is to cycle recordings
of other frequently requested information in hopes of answering their questions
while they are waiting. Many callers may get the information they require
from those messages and no longer need to wait for assistance. This ensures
that staff is assisting those who could not be helped easily by other means.
The recordings can also refer callers to other information sources (such
as the Internet) that they may opt to explore instead of waiting in queue
or investigate first before calling back.

We have found this most effective for inquiries about finding flu vaccination
sites that could be easily located via a Web site. We typically cycle a recording
stating, "We are experiencing high call volumes at this time; please
consider calling back at another time," for those in queue for more
than a few minutes. Callers appreciate being kept informed about wait times,
and technology that estimates queue times for callers can be used.

Assuming that messaging will work for a majority of callers, the number
of staff and phone lines required to deliver information to the same number
of callers can be decreased. Here is the example that we used for calculating
the resources needed to handle 28,000 callers depending on an event lasting
from 1 to 5 days.

Event Duration (Days)

1

2

3

4

5

Average Calls/Day

28,000

14,000

9,333

7,000

5,600

Staffing (FTE)

354

181

123

93

76

Phone Lines

401

213

148

116

95

The more callers who can be handled effectively with messaging strategies,
the fewer staff and phone lines will be needed (good recorded messages can
deliver information consistently and at a constant rate).

Event Duration (Days)

1

2

3

4

5

Agent Calls/Day

11,200

5,600

3,733

2,800

5,600

Message Calls/Day

16,800

8,400

5,600

4,200

3,360

Staffing (FTE)

146

76

52

40

33

Phone Lines

174

95

68

54

45

These calculations assume that only 40 percent of callers speak with an
agent for an average call length of 293 seconds, including after call activities;
the remainder receive only messages/recordings.

Furthermore, by reviewing the concerns of callers speaking with staff, managers
can determine if additional information should be added to the initial announcement,
added to queue messages, or disseminated by the media or other sources in
hopes of meeting demand without call center staff involvement.

All of these strategies for providing information to the greatest number
of callers with limited resources greatly assisted us in handling the call
volumes related to the 2003/2004 influenza season. From November 17, 2003
to January 31, 2004, HELP received almost 24,000 calls with peak call volumes
of 7,145 weekly, 2,565 daily, and 345 hourly. During influenza seasons, many
callers are trying to locate vaccination sites. We have successfully referred
callers with Internet access to a Web site that they can easily use to find
these locations in Colorado. We provided the direct URL address in our initial
announcement to off-load many callers to this resource.

Our information providers use the same Web site to assist callers in finding
vaccination locations. The announcement content seemed to be effective, since
those who waited to speak to staff for that reason prefaced it by saying
"Sorry, I know I could use the Internet, but I do not have access."
A reporter doing an influenza story showed viewers how to locate vaccination sites
using a computer on the air and assisted in reducing the overall HELP call volume
almost immediately. Partnering with media can greatly assist in providing
the most requested information and reducing the demand on hotlines during
events.

IR Applications Evaluation

It is the challenges we encountered with surges in demand to HELP that led
us to develop and test the four IR applications.
Appendix 4 provides the
full details of the two exercises used to evaluate the applications. This
is a brief summary of those exercises and user feedback about improving each
application:

Quarantine/Isolation (QI) Monitoring.

Point of Dispensing (POD) Locations.

Drug Identification (DI).

Frequently Asked Question (FAQ) Library.

Quarantine/Isolation Monitoring. A prototype version of the QI Monitoring
Application was tested in 12 rural volunteers who served as "isolation
cases" in conjunction with an influenza vaccination exercise in October
2005. Data were collected in the volunteers and entered into the State health
department's Outbreak Management System.

The application was revised to reflect many of the user suggestions. In
an exercise in May 2006, the revised and more fully developed QI Monitoring
Application and the other three applications were evaluated in an urban user
group consisting primarily of local health personnel from 10 counties. The
goal of the second exercise was to test the ability of the four IR applications
either to initiate contact and determine health status of those in quarantine
or to effectively communicate key information to users calling in to the
applications.

An issue realized from this exercise was that the application could not
guarantee quarantine compliance. Even if someone answered the application
during every calling period, there was no way to prevent another person from
answering on behalf of the person in quarantine. Requiring entry of data
to specific prompts like "last 4 digits of social security number" would
not guarantee the identity of the person who answered, as almost any identifying
information could be shared with another. Adding confirmatory prompts would
make the application more complicated and could result in more people finding
it difficult to use while being in compliance.

Agencies using home quarantine strategies could consider certain qualifications
for individuals to reduce undetected circumvention, such as requiring a land
line (and not a cell phone) for contact and agreeing to have call forwarding
features disabled. Therefore, it will be important to develop effective risk
communication messages to the public and adequate support for those in quarantine
to assure good overall compliance. Public health agencies will find it difficult
to monitor individuals in home quarantine without strategies to reduce the
need for staff.

This application monitored up to 70 percent of quarantined persons demonstrating
compliance with few personnel resources. The QI Monitoring Application (or
some similar monitoring strategy) will permit limited staff resources to
concentrate on obviously noncompliant individuals and those with additional
needs or to manage the myriad of other response actions required in a health
emergency.

The second version of the QI Monitoring Application required the person
answering the call to indicate their most current temperature reading as
an objective means to monitor their health status. The public health departments
helping to design this exercise believed that providing a thermometer to
everyone in quarantine would be realistic and would help to identify those
potentially developing signs of illness. Those selecting the option for a
temperature reading of less than 100oF were considered well but also were
given an option to select if they needed to speak to someone. Those selecting
the option for a temperature reading equal to or greater than 100oF or who
indicated difficulty in taking their temperature were transferred to the
HELP service for assistance. For testing results of the second version, go to Appendix 4.

Concern was raised about whether this application could work for everyone,
including the elderly and those with special needs. It was never our intention
that the application could work for everyone, rather that it could work for
most. It would be at the discretion of public health agencies coordinating
quarantines to decide which individuals this application could assist in
monitoring, thereby freeing resources to monitor those with additional or
special needs.

Drug Identification (DI). The DI Application was tested to
determine how effective such an application would be to assist the public in identifying
antibiotic drugs that may be dispensed during certain public health events.
The underlying challenge is that more than one brand of the same medication
will be distributed to the same household during an emergency, and each may
have a different appearance. For example, there are several manufacturers
of doxycycline. Figure 6 contains
the five different appearances of 100 mg doxycycline preparations that are
contained in local and national stockpiles. This IR application offers a
self-service alternative for callers to correctly identify drugs by type
(capsule or tablet), shape, color, and imprints rather than calling their
doctor or pharmacist. The application can identify, in addition to doxycycline,
ciprofloxacin and Levaquin, which are other antibiotic drugs in many local
stockpiles.

Point of Dispensing (POD) Locations. The POD application
was tested to determine if callers entering their 5-digit zip code could get
correct POD locations in a self-service manner. This application could be modified
to provide any zip-code-specific information and to ensure:

Consistent, accurate information based on zip code.

Collection of zip code data to characterize events (situational awareness—caller
locations and the potential need for more media messaging).

Expanded capacity for handling surges since calls are handled
without personnel.

Support for mass prophylaxis/immunizations, evacuations, or sheltering
in place information.

Volunteers were assigned to evaluate this application by calling a toll-free
number, entering a 5 digit zip code, and recording that zip code and the
location they were given on an evaluation form. We received all evaluations
back (100 percent return rate), and all recorded the correct POD location
for their entered zip code.

Frequently Asked Question (FAQ) Library. The FAQ Library Application was
tested to evaluate the ability of users to navigate a library of messages
and to obtain desired information. Our HELP program uses this library for
handling callers after hours with great success by allowing self-service
information delivery that is consistent and accurate. The application collects
entered data to characterize the information needs of the public (the entered
zip code for situational awareness—identifying public information needs
and where to target them). The application is able to expand capacity for
handling surges and is capable of adapting to different events.

We met our overall exercise objectives and obtained excellent feedback to
improve the tested applications. We also obtained important information on
user acceptance for these IR applications. Although evaluations were mostly
favorable for all four applications, the FAQ Application seemed more acceptable
than the DI Application (perhaps because the latter concerned medications
to be taken). The comments and evaluations of these applications should help
public information officers in determining which ones may be acceptable for
different events and in developing messaging strategies. These results also
suggest areas for potential community outreach efforts for public health
agencies to create a more informed public. One lesson learned is that the
tools will be only as good as the information that is developed for them
and how it is provided to the public.